Being Transgender: The Then and Now of Medicine and Psychology

Transgender is defined as a person whose gender identity differs from the sex the person had or was identified as having at birth.

It’s a bit more complex than that; consider the stigma that comes with identifying as transgender. During a Ted Talk, Dr. Norman Spack, Endocrinologist, explains it well, “[sex is] a description of your genitals,” this is what you were labeled with at birth. People also tend to confuse sexual orientation and gender identity. “Sexual orientation is who you go to bed with, gender identity is who you go to bed as,” Dr. Spack. Transgender medicine has changed drastically, and for the better over time, while psychology has yet to catch up.

The medicine connected with transgenderism has evolved over time. The “Father of Transgender Health Care” Magnus Hirschfeld, defined the term Transvestite as the desire to express one’s gender in opposition to their defined sex. This acted as a gateway to the supply of sex change therapies. One of the first known, and more famous cases, is that of Lili Elbe, born Einer Wegener. While everyone else was looking to cure her, Dr. Hirschfeld offered to help at his Institute of Sexual Science in Berlin. Starting in 1930, Hirschfeld performed a total of five reconstructive surgeries on Lili, but unfortunately she died of infection complications in 1931. In 1922, he performed castration of Dora Richter, one of the institute employees. Then in 1931 successfully completed her sex reassignment surgery. (Khan)

The 1940’s brought pioneers Alfred Kinsey and Henry Benjamin to the United States. Kinsey was a biologist who founded the Institute for Sex Research at Indiana University, also known as the Kinsey Institute, in 1947. He helped introduce America to the transgender concept. Christine Jorgenson, the first American to receive sex reassignment surgery, had to do so in Berlin, as resources were limited in the United States. The physician that performed her surgery, Dr. Christian Hamburger, received many letters from other Americans after word of the successful procedure. Hamburger referred these people to Endocrinologist, Henry Benjamin, who had offices in New York and San Francisco. Benjamin had spent time with Hirschfeld at his Institute in Berlin, and believed in the same principle; that those who feel their sex to be divergent from their gender, deserve treatment and not psychotherapy for a cure. Thanks to these men, a foundation for modern transgender health care was laid. (Khan)

Modern sex reassignment surgeries are less dangerous and are done so only after considering the patient’s mental health. The WPATH criteria state that the patient must have persistent, well-documented gender dysphoria, the capacity to make a fully informed decision and to consent for treatment, they must be of the age of majority in a given country, and if significant medical or mental health concerns are present, they must be reasonably well controlled. There is also a letter of documentation required from the attending mental health professional before surgery can be considered (WPATH.org). Once all of these specifications are met, there are a plethora of surgeries to be considered, based on the outcome desired. Those who are transitioning from Male-to-Female (MTF) have the options of breast augmentation, genital surgery including vaginoplasty and orchiectomy, and facial feminization surgeries. The vaginoplasty and orchiectomy are not so different from earlier surgeries performed by Dr. Hirschfeld. Those transitioning from Female-to-Male (FTM) may want to consider chest surgery to remove the breasts entirely, or even a phalloplasty. A hysterectomy may be recommended by the physician as there is debate about the long-term effects of testosterone on the reproductive system (Teich 52-55).

Not all who identify as transgender may want to undergo surgical options. There are hormone therapies that are very successful in changing the appearance of the transgender person. For transwomen, MTF, hormone therapy is a two-step process. First, the patient must take a hormone to block testosterone, androgen suppressants, then there is the administration of estrogen. Estrogen may be taken in multiple forms such as pill, skin patch or injection, and tends to be a lifelong treatment. This treatment will help to increase breast tissue, decrease body hair, redistribute body fat, and create a softer skin texture. The voice, however, will not be effected. Transmen, FTM, do not have a need for suppressants of any kind, as testosterone (T) is more powerful than estrogen. T is usually injected, but can tend to cause highs and lows in this form. There are also skin patches and topical gels that can ensure a steadier hormone level. When taking a regimen of T, menstruation ceases, body and facial hair grow, voice pitch will lower, body fat will redistribute, and skin texture may become more coarse (Tiech 48-51).

The topic of gender dysphoria is being more openly talked about which has led to more adolescent and young adults coming out as transgender. There are advanced hormone therapies for those of adolescent age these days. Dr. Norman Spack brought a new treatment, coming out of Holland, to the United States. Using a puberty blocking hormone can give young adults time to affirm who they feel they are. This hormone is given around 12 years of age and is completely reversible. If the decision is to go ahead with hormones of the opposite sex, after re-evaluation, this happens at 16 years old. Then at 18, these persons are eligible for gender reassignment surgery (Spack). This treatment is revolutionary, stopping puberty for those who identify with the opposite sex and giving them the chance to grow physically and mentally as the person they know they are.

Psychology for those who identify as transgender, got off to a bit of a rocky start. In the early 1900’s it was thought that transgender, but especially male to female patients, were schizophrenic and in need of a cure for their affliction (Khan). Treatments included fever therapy, which sometimes meant injections of Sulphur or oil, and electroshock therapy. Transgender, known as Gender Identity Disorder (GID) in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM), only recently became known by the term Gender Dysphoria in a newer edition. Gender dysphoria is a mental health condition where the person desires to be the opposite sex of that with which he or she was born. Only seven of the 943 page DSM are dedicated to GID, and it is listed under Sexual Disorders; just after paraphilias, which includes disorders such as exhibitionism and pedophilia (Teich 79,80).

While there are standards of care defined by WPATH, formerly know as the Henry Benjamin International Gender Dysphoria Association, there is still no education for those in psychiatry on the topic of gender dysphoria. Mental health professionals are often referred to as “gatekeepers” in this situation. The person seeking hormone therapy, or any other transition procedure, must obtain a letter to do so. Before the letter can be written, an evaluation is needed by a mental health professional; the transperson must verify that they know the risks and benefits associated with the procedure (Teich 95,96). Without knowledge of gender dysphoria it is entirely possible for some psychiatrists to end up doing more harm than good; as it is up to the individual to do their own research and rely on their values, morals, and intuition about their patient’s situation. The WPATH standards of care provide guidance, recommending that those working with someone living with gender dysphoria:

Have a masters degree or it’s equivalent in a clinical behavioral science field.

Have competence in using the Diagnostic Statistical Manual of Mental Health Disorders and/or the International Classification of Diseases for diagnostic purposes.

Have the ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria.

Are knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria. (WPATH.org)

While this is helpful, it is not legally binding. Those seeking help in these situations should also do their own research about the provider most suitable for them.

It is impressive, the leaps and bounds, that medicine has made, but there is more to come. The research taking place now will help us to better understand gender dysphoria and the people it affects. Psychology needs to and will become better acquainted with treatment in regards to transsexual, transgender, and gender nonconforming people.

Mandy Baird, I am a Medical Assistant turned nursing student. I have been in the health care field since 2006, first as a Volunteer Firefighter/EMT. In 2008 I moved into the Emergency Department, where I’ve been ever since. I am in pursuit of my BSN at this time, and plan to stay in emergency medicine. I wrote this paper/article for an English assignment, but have chosen to share it with this online community in hopes of educating the general public about what it means to be transgender. It is something that is being talked about more often, but is still not well understood; the lack of understanding and education breeds hate and discrimination. I hope that this article will enlighten some of those people.